Background

It is well known that systemic barriers based on cultural beliefs and stigma prevent persons of Caribbean origin living with HIV from learning their HIV status and accessing care. This is confirmed by the social support literature which has found that the behaviors of individuals are affected by the social norms of their communities.

Interventions that address social network and community-level phenomena, have been shown to be effective in reducing HIV risk behaviors in diverse populations. These interventions have included enlisting peer counselors who are trained to communicate, encourage, and reinforce health-protective messages. A peer counseling intervention that addresses the characteristics of the targeted population and the interactions between clients and their providers offers a potential solution to retaining Caribbeans living with HIV into care and achieving their appropriate utilization of care.

This Special Projects of National Significance (SPNS) initiative was intended to strengthen and evaluate community-based peer programs that serve people living with HIV who are of Caribbean origin. Five demonstration sites, in conjunction with the SPNS Program and an Evaluation and Support Center, developed, implemented and evaluated peer support interventions designed to enable Caribbeans living with HIV disease to understand the nature of their HIV infection and HIV treatment options, and obtain HIV medical and ancillary services. SPNS funded this initiative during Federal fiscal years 2003 through 2006.

Target Population: Haitians living with HIV or AIDS in East Brooklyn, NY

Description: This project examined the development and impact of a culturally specific peer support intervention targeting Caribbeans living in the awardee's general service area. The project identified endemic and culturally specific barriers to care, developing a cadre of peer promoters to assist persons in need of services with overcoming such barriers. It also implemented small group and individualized health education sessions to assist clients with engaging in medical care and using support services. The grantee's process and outcome evaluation of the project used an intervention group and a comparison group design.

Target Population: Jamaican and Trinidadian/Tobagonian immigrants who are HIV-infected and residing in the Bedford-Stuyvesant, Crown Heights, Flatbush and East New York communities of Brooklyn, New York

Collaborating Partners: STAR Health Center at SUNY Downstate Medical Center in Brooklyn, and the New York State Psychiatric Institute/Research Foundation for Mental Hygiene, Inc./HIV Center for Clinical and Behavioral Studies at Columbia University

Description: Caribbean immigrants are disproportionately affected by HIV/AIDS and face numerous barriers to accessing HIV/AIDS care in the U.S. The Caribbean Access Initiative is an empowerment-based, culturally consistent peer-support intervention specifically tailored to address the unique challenges faced by HIV-positive Caribbean immigrants. This HRSA-SPNS demonstration project implemented by Community Healthcare Network, a consortium of eight community clinics in NYC, was designed to increase participants' knowledge and understanding of HIV, HIV treatment options and the service delivery system; reduce barriers to care through skill development; identify effective strategies to increase timely and consistent use of appropriate HIV medical care and ancillary services; and utilize innovative outreach methods, including snowball sampling, to engage this hard-to-reach population.

The intervention consisted of six intensive group sessions and twelve individual peer-participant sessions. Group process enhanced peer support by providing a supportive, non-threatening environment to experiment with new behavior and skills and to receive feedback. Strategies included culturally relevant person-centered participatory approaches, didactic role-playing and vignette analysis. Group session topics included HIV education and myth deconstruction; navigation of the health care system; nutrition and access to ancillary services; male/female condoms; coping skills; and self-efficacy. A Caribbean PLWHA advisory board and key informant interviews frame session content.

Trained peer educators facilitated outreach and intervention sessions. Peer educators were of Jamaican and Trinidadian/Tobagonian origin, HIV-positive and resided in the same NYC communities as participants. Peers received rigorous preparation in the areas of HIV/AIDS education, creating therapeutic environments, effective communication, crisis intervention, group process and burnout prevention.

Description: The TIPS project used peer educators to conduct a culturally-specific individual and community level intervention to communicate HIV related information and influence community norms and values regarding use of HIV related services. Specific goals are to increase knowledge of HIV infection among the target population, increase understanding of HIV treatment options and the service delivery system, and increase entry into appropriate HIV medical care. Recipients of peer services will be compared to a similar group not receiving services. Evaluation strategies included process evaluation; outcomes measurement of the intervention; descriptive evaluation of intervention and comparison groups; measurement of duration and intensity (dose) of the intervention; and measurement of effects on client and community characteristics.

Universityof MiamiSchool of Medicine, Departments of Medicine (Division of Infectious Disease) and Epidemiology and Public Health

Project Title: Enabling Haitians Access to Needed Care (ENHANCE)

Target Population: Haitians living with HIV or AIDS in the Miami-Dade County area

Collaborating Organizations: Jackson Memorial Hospital in Miami, FL

Description: The project developed, implemented, and evaluated a theory-guided peer intervention that sought to enhance use of HIV-oriented primary medical care and ancillary services by the target population. It specifically focused on persons enrolled in care who have not seen a primary care provider for at least six months. Follow-up assessments were conducted at six month intervals to assess the proportion of persons who increase use of medical care and ancillary services. A principal goal was to improve the transition of Haitians from hospital care at Jackson Memorial Hospital to outpatient care.

MontefioreMedical CenterDepartment of Family Medicine and Community Health

Project Title: Targeted Peer Support and Model Development

Target Population: Jamaicans living with HIV or AIDS

Description: This project developed a culturally-specific peer outreach and small group intervention among HIV-infected Jamaicans living in the North Bronx. The project's sought to increase the use of HIV-oriented primary medical care, mental health care, and case management. Peer outreach workers provided current information on HIV and treatment options, address cultural practices and meanings related to sexuality and HIV, and assisted patients with support services such as nutrition education, transportation, and child care. Civic leaders, clergy, and medical providers from the local Jamaican community were enlisted to support the project. The project's evaluation compared baseline data at the project's founding with measurements taken at six-month intervals. The evaluation's focused on use of medical and social services by clients, and the impact of training and intervention activities related to peer outreach workers.

Description: The Evaluation and Support Center assisted the demonstration project sites with implementing and evaluating theoretically-sound, evidence-based, and culturally specific peer support interventions. It also conducted a cross-site evaluation to determine models that are effective for specific groups of Caribbeans living in the US. Finally, it led efforts to identify, compile and disseminate best practices, lessons learned, and other relevant findings to HIV service providers, policy makers, and patients. The Evaluation and Support Center conducted an initial needs assessment, and then designed a structured technical assistance system to provide ongoing TA and also develop and deliver training for peer workers and data collection. Key features of the cross-site evaluation included a cross-site logic model, common data collection instruments and protocols, and a common analysis plan.

The SPNS program began with some of the first Federal grants to target adolescents and women living with HIV, and over the years, initiatives have been developed to reflect the evolution of the epidemic and the health care arena.